From January 2006 to January 2010, a total of 20 men with gynecomastia were treated by an 8-G vacuum-assisted biopsy device. Sixteen (23%) patients had complications and higher resection weight, increased BMI, and older age were found to have statistically significant complication rates with p-values of p<0.001, p=0.034, and p=0.004, respectively.The investigators also found that the incidence of complications was highest among current smokers and lowest among those who had never smoked with a 37% difference in the occurrence of complication (p<0.01). In Type I (idiopathic) gynecomastia, the adolescent presents with a tender, firm mass beneath the areola. 1969;44(235):291-303. A study by Glatt et al (1999) was a retrospective analysis of responses to questionnaires sent to patients who underwent reduction mammoplasty regarding physical symptoms and body image. There are alsoseveral earlier, smaller studies that found reductions in symptoms and improvements in quality of life after reduction mammoplasty (Glatt et al, 1999; Bruhlmannand Tschopp, 1998; Blomqvist et al, 2000; and Behmand et al, 2000). Chemical peels (chemical exfoliation): Considered medically necessary when criteria in CPB 0251 - Dermabrasion, Chemical Peels, and Acne display: none; Vacuum-assisted minimally invasive mastectomy was performed successfully in all cases, with no residual glands or adipose tissue observed on US. The authors also noted that patients with BMI greater than 40 kg/m were significantly more likely to develop postoperative wound complications (p = 0.02). The authors recruited 67 consecutive female patients who underwent inferior pedicle reduction mammoplasty in order to determine the effects of resection weight, BMI, age, and smoking on complication rates following reduction mammoplasty. Ann Plast Surg. Flancbaum L, Choban PS. Mistry and associates (2017) examined outcomes following breast re-reduction surgery using a random pattern blood supply to the nipple and vertical scar reduction. Surgical implications of obesity. Dancey A, Khan M, Dawson J, Peart F. Gigantomastia--a classification and review of the literature. Surgeon. } No other operation-related complications were observed. list-style-type: decimal; It can cause discomfort and concern, resulting in patients seeking diagnosis and treatment. The risks included infection, wound breakdown, scarring, and the need for re-operating. A systematic review of patient reported outcome measures for women with macromastia who have undergone breast reduction surgery. Schnur PL, Hoehn JG, Ilstrup DM, et al. } Nelson JA, Fischer JP, Chung CU, et al Obesity and early complications following reduction mammaplasty: An analysis of 4545 patients from the 2005-2011 NSQIP datasets. Special Clinical Concerns. 1999;103(6):1687-1690. background-color: #663399; Mannu GS, Sudul M, Bettencourt-Silva JH, et al. Current practice patterns of drain usage amongst UK and Irish surgeons performing bilateral breast reductions: Evidence down the drain. color: #FFF; Based largely upon these results, Nguyen et al (2004) reached the conclusion that a trial of conservative management is not an appropriate criterion for insurance coverage, even though responses to the BRAVO questionnaire indicated that operative candidates and hypertrophy controls received at least some pain relief from all of the conservative interventions, and for some conservative interventions, virtually all subjects reported at least some pain relief. In a survey of managed care policies regarding breast reduction surgery, Krieger and colleagues reported (2001)found that mostof the respondentsstated that they use weight of excised tissue as the main criterion for allowing the procedure, with anaverage cut-off value of 472 grams for a typicalwoman. Minor complications (3.2 %) included prolonged swelling, bruising, asymmetries, and residual gynecomastia. Major complications (1.6 %) included unilateral hematoma and localized infection. Ann Plast Surg. } Oxfordshire NHS Trust. Is there a rationale behind pharmacotherapy in idiopathic gynecomastia? 2012;130(4):785-789. Policy Statement 6d: Aesthetic surgery procedures. Liposuction facilitated the easy handling to remove the breast tissue via small incisional design; showed consistent improved QOL in terms of satisfaction after surgery. Answer: Aetna Insurance Breast reduction may or may not be covered depending on your insurance carrier and your breast size. CPT Codes 19316 & 19318 - Mastopexy & Reduction No significant changes have been made to the Obstet Gynecol Clin North Am. Reduction mammoplasty: Criteria for insurance coverage. However, the measuring method of satisfaction rate varied, resulting in difficulties to interpret the results. Hello! Re-operation rate of liposuction-assisted surgery was between 0.6 % and 25 %. Clinical outcomes in reduction mammaplasty: A systemic review and meta-analysis of published studies. 1991;27(3):232-237. Plast Reconstr Surg. Ann Plast Surg. The primary outcome was the difference in wound drainage over 24 hours. And if you are in Canada the surgeon decides. list-style-type : square !important; Krieger LM, Lesavoy MA. A total of 15 articles met the inclusion criteria for review. Srinivasaiahet al (2014) stated that although reduction mammoplasty has been shown to benefit physical, physiological, and psycho-social health there are recognized complications. Open surgery was performed in 56 patients, and vacuum-assisted breast biopsy was performed in 27 patients. Examining any complication, a significant increase was noted with increasing obesity class (p < 0.001). Autorino R, Perdona S, D'Armiento M, et al. Sood R, Mount DL, Coleman JJ 3rd, et al. Orthopedic or spine surgeon evaluation of spinal pain; Radiotherapy (for the prevention or management of gynecomastia recurrence); Vacuum-assisted breast biopsy system for treament of gynecomastia. Current concepts in gynaecomastia. position: fixed; There were no restrictions on the basis of date or language of publication. color: red!important; This was further isolated when comparing morbidly obese patients to non-obese (p < 0.001), class I (p < 0.001), and class II (p = 0.01) patients. In a systematic review, Prasetyono and colleagues (2021) examined the quality of studies and re-visited liposuction-assisted gynecomastia surgery performed via minimal incision. American Society of Plastic and Reconstructive Surgery (ASPRS). Nelson et al (2014a) analyzed population data from the 2005-2010 American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. The authors concluded that treatment of gynecomastia by the Mammotome device was distinctive, practicable in manipulation, safe, and could achieve excellent cosmetic results. Several of the included studies reported improvement in QOL and several psychological domains after surgical treatment for gynecomastia. The Mammotome procedure represented another novel therapeutic option for gynecomastia. These individuals cite evidence from observational studies to support this position (e.g., Chadbourne et al, 2001; Kerrigan et al, 2001). Med Decis Making. #backTop:hover { font-size: 18px; 1998;26(1):61-65. 2nd ed. Kerrigan CL, Collins ED, Kim HM, et al. 2009;7(2):114-119. } OL OL LI { These investigators analyzed the incidence of occult breast cancer and high-risk lesions in reduction mammoplasty specimens of women with previous breast cancer. Estrogens and estrogen like drugs,including: Drugsthat enhance estrogen formation, including: Drugs which inhibit testosterone synthesis, including, Drugs that inhibit testosterone action, including. ul.ur li{ Causes may include testosterone-estrogen imbalance, increased prolactin levels, or abnormal serum binding protein levels. Follow-up ranged from 2 months to 3 years. Asian J Surg. In the case of breast reduction, however, for insurance purposes, it . Cochrane Database Syst Rev. cursor: pointer; Variations in pattern of pubertal changes in girls. Aesthetic Plast Surg. and areola. The authors specified the value of these study results was in the identification of morbid obesity as a significant predictor of overall morbidity and active smoking as a strong predictor of major surgical morbidity. Impact of surgical treatment for gynecomastia appeared to be beneficial for several psychological domains. .arrowPurpleSmall, a:hover.arrowPurpleSmall { The investigators found little difference between obese and non-obese women concerning patient's reports of resolution of symptoms and improvement in body image. Reduction (or some cases augmentation) mammoplasty and related reconstructive procedures on the unaffected side for symmetry are also considered medically necessary. 2013;71(5):471-475. Reduction mammaplasty. Plastic Reconstr Surg. Plast Reconstr Surg. 1996;20(5):391-397. These investigators concluded that their findings do not support the use of completely autologous platelet gel to improve outcomes after reduction mammoplasty. Fat grafting volume ranged from 50 to 300 cc in each pectoral muscle. 2007;36(2):497-519. These investigators searched the literature on the treatment of Simon's grade I and II gynecomastia in PubMed, Scopus, Science Direct, and Cochrane using keywords "gynecomastia" and "liposuction". Surgical treatment of gynecomastia by vacuum-assisted biopsy device. Long-term functional results after reduction mammoplasty. Aetna considers magnetic resonance imaging (MRI), with or without contrast materials, of the breast medically necessary for members who have had a recent (within the past year) conventional mammogram and/or breast sonogram, in any of the following circumstances where MRI of the breast may affect their clinical management:. .strikeThrough { 2015;10(8):e0136094. Aesthet Surg J. Inclusion criteria were as follows: men diagnosed with gynecomastia and BMI of less than or equal to 32 kg/m2, adequate skin elasticity, and general good health. Most UnitedHealthcare plans have a specific exclusion for breast reduction surgery except as required by the . Hoyos AE, Perez ME, Dominguez-Millan R, et al. American College of Obstetricians and Gynecologists (ACOG), Committee on Adolescent Health Care. Li CC, Fu JP, Chang SC, et al. Liposuction assisted gynecomastia surgery with minimal periareolar incision: A systematic review. 2015;49(6):311-318. They evaluated the use of radiotherapy for the prevention and treatment of gynecomastia incidence or recurrence by plastic surgeons. The average age was 24.7 years (range of 18 to 47 years). Bertin ML, Crowe J, Gordon SM. 2005;55(3):227-231. 1995;34(2):113-116. The authors concluded that even with the high level of evidence demonstrating the safety of BBR without drains, they are still routinely utilized. Reduction mammaplasty: An outcome study. Two patients experienced unilateral minor partial necrosis of the areolar edge but not of the nipple itself (2 %). Disproportionately large breasts can cause both physical and emotional . Plast Reconstr Surg. Tang CL, Brown MH, Levine R, et al. The authors concluded that the incidences of malignant and high-risk lesions were doubled compared to patients without prior breast cancer. Abnormal histopathological findings were more frequent in patients with reduction mammoplasty performed prior to oncological treatment (p < 0.001), and in patients with immediate reconstruction (p = 0.0064). Reduction mammoplasty for macromastia. Reduction mammoplasty: Cosmetic or reconstructive procedure? Managed care's methods for determining coverage of plastic surgery procedures: The example of reduction mammaplasty. Approximately 25 % of the 49 subjects included in this study did not return the post-operative questionnaire. Preoperative patient factors and comorbidities, as well as intraoperative variables, were assessed. They also analyzed if timing of reduction mammoplasty in relation to oncological treatment influenced the incidence of abnormal findings, and compared if patients with abnormal contralateral histopathology differed from the study population in terms of demographics. Grade IV: Marked breast enlargement with skin redundancy and feminization of the breast. All subjects were satisfied with their cosmetic outcome, graded as excellent by 22 patients (100 %). 2010;125(5):1301-1308. Aetna considers breast reduction surgery medically necessary for non-cosmetic indications for women aged 18 or older or for whom growth is complete (i.e., breast size stable over one year) when any of the following criteria (A, B, or C) is met: Macromastia: all of the following criteria must be met: .strikeThrough { Although operative subjects were examined before and after surgery, there was no attempt to employ any blinded or objective measures of disability and function to verify these self-reports. Vacuum-assisted minimally invasive surgery was carried out under general anesthesia; subjects were followed-up with physical examination and ultrasonography (US). bottom: 20px; They concluded that higher resection weight, increased BMI, older age, and smoking are risk factors for complication and that patients should therefore be adequately counseled about losing weight and stopping smoking. These investigators presented their experience with pectoral high-definition liposculpture combined with inverted-omega incision resection for gynecomastia. Aetna has their own sliding scale which requires more from smaller patients relative to the Schnur scale, but maxes out at 1000 gms per breast. Arlington Heights, IL: ASPS; May 2011. background-color:#eee; These studies did not find a relationship between breast weight or amount of breast tissue removed and the likelihood of response or magnitude of relief of pain after reduction mammoplasty. 2020 Sep 4 [Online ahead of print]. 1997;185(6):593-603. Harmonic scalpel versus electrocautery in breast reduction surgery: A randomized controlled trial. 2006;9(2):109-114. Annu Rev Med. Howrigan P. Reduction and augmentation mammoplasty. A study by Bruhlmann and Tschopp (1998) was a retrospective study of 246 patients from a surgical practice, approximately 50 % (132) of whom returned a questionnaire about their symptoms and satisfaction with aesthetic results, and their recollection of symptoms prior to surgery. Nor is it intuitively obvious that removal of smaller amounts of breast tissue would offer significant relief of back, shoulder or neck pain. Wound drainage after plastic and reconstructive surgery of the breast. Plast Reconstr Surg. Sabistons Textbook of Surgery (Burns & Blackwell, 2008)states that breast size should be stable for one year: There is no set lower age limit but, for the adolescent with breast hypertrophy, reduction is deferred until the breasts have stopped growing and are stable in size for at least 12 months before surgery.. For these reasons, there is insufficient evidence to support the use of reduction mammoplasty, without regard to the size of the breasts or amount of breast tissue to be removed, as a method of relieving chronic back, neck, or shoulder pain. Brown DM, Young VL. Gynecomastia may be drug-induced. 2001;107(5):1234-1240. Two review authors undertook independent data extraction of study characteristics, methodological quality and outcomes (e.g., infection, other wound complications, pain, and length of hospital stay [LOS]). Breast reconstruction/breast enlargement Breast reduction/mammoplasty Excision of excessive skin due to weight loss Gastroplasty/gastric bypass While the efficacy of radiotherapy as a therapeutic modality for gynecomastia was also established, it was shown to be less effective than other available options. Drains were used significantly less by surgeons performing greater than or equal to 20 BBRs (p = 0.02). 2015;49(6):363-366. N Engl J Med. the nipple-areola complex can be elevated by de-epithelialization rather than recreating or developing a new pedicle; breast tissue is removed where it is in excess, usually inferiorly and laterally; the resection is complemented with liposuction to elevate the bottomed-out inframammary fold; and. Breast and aesthetic surgery. The member has gigantomastia of pregnancy accompanied byany of the following complications, and delivery is not imminent: For medical necessity criteria for surgery to correct breast asymmetry, seeCPB 0185 - Breast Reconstructive Surgery. Kalliainen LK; ASPS Health Policy Committee. If an insufficient amount of breast tissue is removed, the surgery is less likely to be successful in relieving pain and any related symptoms from excessive breast weight (e.g., excoriations, rash). Breast Concerns of Adolescents. Plast Reconstr Surg. Health insurance companies frequently have different criteria for whether breast reduction surgery is medically necessary. The American Society for Plastic Surgery (2011) advises to delay surgery until breast growth ceases: Although waiting may prolong the psychological awkwardness, it is advisable to delay surgery until breast growth ceases in order to achieve the best result. This is similar tothe American College of Obstetricians and Gynaecologists'2011 Guidelines forAdolescent Health Care chapter on breast concerns in adolescents, which states regarding breast hypertrophy: Preferably, treatment should be deferred until breast growth has been completed. Last Review01/04/2023. Aetna considers molecular susceptibility testing for breast and/or epithelial ovarian cancer ("BRCA testing") medically necessary once per lifetime in any of the following categories of high-risk adults with breast or epithelial ovarian cancer (adapted from guidelines from the U.S. Preventive Services Task Force (for Analysis was on an intention-to-treat basis. Schnur subsequently refuted the validity of the Schnursliding scaleand stated that thescale should no longer be used as a criterion for the determination of insurance coverage for breast reduction surgery (Nguyen et al, 1999). For example, if the body surface area is 1.40 m2 , the estimated breast tissue to be removed should at least be 324 grams. For additional language assistance: Chemical exfoliation for acne (eg, acne paste, acid), Mastectomy, partial (e.g., lumpectomy, tylectomy, quadrantectomy, segmentectomy), Diagnostic mammography, including computer-aided detection (CAD) when performed, Photodynamic therapy by external application of light to destroy premalignant and/or malignant lesions of the skin and adjacent mucosa (eg, lip) by activation of photosensitive drug(s), each phototherapy exposure session, Photodynamic therapy by external application of light to destroy premalignant lesions of the skin and adjacent mucosa with application and illumination/activation of photosensitizing drug(s) provided by a physician or other qualified health care professional, per day, Basic life and/or disability examination that includes: Measurement of height, weight, and blood pressure; Completion of a medical history following a life insurance pro forma; Collection of blood sample and/or urinalysis complying with "chain of custody" protocols; and Completion of necessary documentation/certificates, Weight management classes, non-physician provider, per session, Mononeuropathies of upper limb [upper extremity paresthesia], Gangrene, not elsewhere classified [tissue necrosis], Non-pressure chronic ulcer of skin of other sites, Hypertrophy of breast [symptomatic-causing significant pain, paresthesias, or ulceration], Other specified disorders of breast [soft tissue infection]. If breast growth has been completed, breast reduction surgery is an option. Marshall and Tanner (1969)shows that the final stage of breast maturityoccurs about age 15 on average, but there is wide variation. Subjects responses were compared to an age-matched comparison group of women, although no further details about how this comparison group were provided. Surgical treatment is indicated when medical treatments fail. An 18-question survey was created evaluating various aspects of BBR practice; UK and Irish plastic and reconstructive and breast surgeons were invited to participate by an e-mail containing a link to a web-based survey. ER expression did not correlate with the right (p = 0.51) and left 2D: 4D (p = 0.97). Gynecomastia has been classified into2 types. Furthermore, no serious complications were observed in vacuum-assisted breast biopsy group. color:#eee; Study appraisal was carried out using MINORS to evaluate the methodological quality of the paper. The majority of patients had previously undergone primary breast reduction using an inferior pedicle [n = 37 (41 %)]. Following treatment, 90.1 % (n = 73) had a complete response of their gynecomastia with tamoxifen therapy. In the case of reduction mammoplasty for relief of back, neck and shoulder pain, Aetna has considered this procedure medically necessary in women with excessively large breasts because it seems logical, even in the absence of firm clinical trial evidence, that this excessive weight would contribute to back and shoulder pain, and that removal of this excessive breast tissue would provide substantial pain relief, reductions in disability, and improvements in function. } The authors concluded that the vacuum-assisted breast biopsy system could be used as a feasible and minimally invasive approach for the treatment of gynecomastia. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. The condition not only must be unresponsive to dermatological treatments (e.g., antibiotics or antifungal therapy) and conservative measures (e.g., good skin hygiene, adequate nutrition) for a period of 6 months or longer, but also must satisfy criteria stated insection I above. padding: 10px; Breast cancer found at the time of breast reduction. Kinell I, Baeusang-Linder M, Ohlsen L. The effect on the preoperative symptoms and the late results of Skoog's reduction mammoplasty: A follow-up study on 149 patients. 1999;103(6):1682-1686. A retrospective study of changes in physical symptoms and body image after reduction mammaplasty. Plast Reconstr Surg. Ann Chir Plast Esthet. Of these 33 operative sides, 2 complications occurred, but satisfactory chest contour was attained in all subjects. Merkkola-von Schantz PA, Jahkola TA, Krogerus LA, Kauhanen SMC. } Photographs were taken pre-operatively and 1, 3, 6, and 12 months post-operatively. These investigators support its use for idiopathic gynecomastia in eligible men following the careful discussion of its risks and benefits. A lack of correlation between these variables may result from the fact that the analyzed group of men with idiopathic gynecomastia was small in number, but at the same time, it appeared to be homogenous in these aspects (positive ER and/or PR expression and high digit ratio). Breast J. Management of gestational gigantomastia. # font-weight: bold; Radiotherapy for prevention or management of gynecomastia recurrence: Future role for general gynecomastia patients in plastic surgery given current role in management of high-risk prostate cancer patients on anti-androgenic therapy. Reduction mammoplasty performed solely for cosmetic indications is considered by insurers to be not medically necessary treatment of disease and subject to the standard cosmetic surgery plan exclusion. Miller AP, Zacher JB, Berggren RB, et al. For example, at a body surface area of 1.5m, Aetna requires a minimum weight of 385 grams removed from each breast, whereas the Schnur scale would only require 260g. Safran and colleagues (2021) noted that several technologies and innovative approaches continue to emerge for the optimal management of gynecomastia by plastic surgeons. Plastic Reconstr Surg. Results illustrated that 3050 patients were <60 years of age (39.7 11.8 years) and 487 were 60 years of age (65.1 4.7 years). Patients were randomized to receive the gel applied to the left or right breast after hemostasis was achieved; the other breast received no treatment. In this study the National Surgical Quality Improvement Program data set was queried for the Current Procedural Terminology code 19318 from the years 2005 to 2010, with principal outcome measurements of wound complications, surgical site infections, and reoperations. Often times, insurance company will dictate how much breast tissue to be removed. This study included 35 patients who underwent breast reduction due to the idiopathic form of gynecomastia. Often, you'll be eligible for Blue Cross Blue Shield breast reduction coverage if your surgeon plans to remove at least 500 grams of breast tissue per breast. All RCTs that compared the use of a wound drain with no wound drain following plastic and reconstructive surgery of the breast (breast augmentation, breast reduction and breast reconstruction) in women were eligible.